Doug, as to why it isn't optional, I don't know, but I'm guessing that the government doesn't want people to be on the dole any more than they are becausethey opted out of Social Security, but didn't save their money, and/or lost it in the stock market and therefore at age 65 have absolutely zero.

It's not that much money, but it's something. If you want more, we all do, you have the right to a private pension plan.

Frankly, since this is the Health Care thread, I like the idea of a base medical plan with the right to a deluxe private insurance plan supplementing the base plan.

No one should go hungry, i.e. Social Security, and IMHO no one should go without a basic Health Care plan.

Maybe the part I'm having a hard time with is that they have a separate pension pan that comes from what is ultimately taxpayer dollars...they vote on what they're going to pay themselves ..self employed people get taxed at 10.4% whereas they pay 6.2% that goes to social security and yet another percentage to their festal pension which doesn't feed into social security at all, every penny of which comes right out if our pockets... they then have the audacity to dip into then funds for social security and to keep this in line with Buraq's health care, I'm quite detain we don't need government driven incompetence in anything else whilst they're up there busy awarding themselves for their "hard work" year.

So JDN, if I pay two cents to support my elders every year, am I paying into Social Security?

Yep, Gator Bait, if you work hard, but all you can earn is $.50 per year, then you are right, you will pay two cents to supportyour elders, like younger Americans will support older Americans, and their young support them, but with your 2cents you have done your part. Congratulations.

By the way, that is mathematically how ALL defined benefit pension plans work, even in private industry. If you would like an actuarial explanation, let me know. Or maybe it would be good for you to look it up.... Facts and research seem to be a problem for you....

Facts and research? Facts like the government is woefully inefficients and if you want them to their your money around that's fine, but they're but going to do it with mine. Facts like elected members of Congress routinely exempt themselves from laws that they subject us too?You can be ad liberal ad you want with your money...not mine.

" I like the idea of a base medical plan with the right to a deluxe private insurance plan supplementing the base plan"

Good thing I am sitting down or the shock might be too much for me! A sound offering from JDN!

If there govt. were to limit itselft to a simple base medical plan I think we would be able to find a grand politifcal compromise that everyone could live with. Unfortunately the next year the progressives would be pushing for more and demanding "compromise" if they didn't get it.

Doug, as to why it isn't optional, I don't know, but I'm guessing that the government doesn't want people to be on the dole any more than they are becausethey opted out of Social Security, but didn't save their money, and/or lost it in the stock market and therefore at age 65 have absolutely zero.

It's not that much money, but it's something. If you want more, we all do, you have the right to a private pension plan.

Frankly, since this is the Health Care thread, I like the idea of a base medical plan with the right to a deluxe private insurance plan supplementing the base plan.

No one should go hungry, i.e. Social Security, and IMHO no one should go without a basic Health Care plan.

JDN: "I like the idea of a base medical plan with the right to a deluxe private insurance plan supplementing the base plan....no one should go without a basic Health Care plan.

Crafty: "A sound offering from JDN!"

It could be a tax on the base of income like SS, and a tax credit for buying the base policy, not a new power, private purchase mandate. Regressive, but so is Obamacare.

What is interesting is that IF the JDN plan was what the Pelosi-Reid-Obama conspiracy had done in the first place, then the argument they were making to the Supreme Court would be true. Force the able bodied to pay their own way, one way or another, for the unexpected emergency services they will most certainly consume. Instead they went for the cradle to grave, social engineering, one size fits all, like it or not route, making the people who don't want to pay the 1/6th of what they consume pay the whole thing that the others consume for healthcare.

I made a trip to the emergency room recently, an interesting experience, my first time in since losing a pedestrian vs. car fight as a kid.

I went into an inner city ER and it was packed with people waiting and I walked out. Drove way out past my home to an exurban hospital and found the place empty with a ready and waiting entry clerk. In screaming pain she had me sit to answer a few questions - quite a few questions - and sign a few forms.

It seems to me, two things: 1) The poor already get free, taxpayer paid health care with or without Obamacare, and 2) if I was not poor but not insured they could have me sign one more form, essentially a patient loan acceptance like a student loan or home mortgage that would ever be forgiven, not even in bankruptcy, until paid. If you are financially able, you are financially responsible. (Imagine that.) Then if young people know these debts will stay with them the rest of their lives, some might choose to buy an affordable, emergency care policy.

You should not have to (by federal law) buy coverage for afflictions that do not apply to you, elective surgeries, routine care that could be fee for service, gender changes and the like, even for heroically expensive efforts to save your life against thin odds like transplants etc. Those could be based on 'choice' or based in the tax system if we so choose. Those rich enough or sufficient in financial responsibility could pledge assets up to the minimum so that doing business with the evil private insurance company is not a universal citizen mandate. You could work, earn, save your way out of it.

JDN bucks the liberal mantra (for just a moment) that whatever the most exotic, expensive medical procedure that any rich person is allowed to buy for themselves must then be extended to all. Two Americas?

"The Obama administration is employing an aggressive ground game to build support for its controversial healthcare law that often reaches beyond the Beltway."

True. But the 'popular' provisions for the most part were on the table in Republican proposals at the time Dems chose to go it alone.

Romney and supporting groups have been quite proficient converting facts into negative ads. The Pelosi-Reid congress and Obama are all on the ballot this time, exposed for one thing on the process of passing healthcare.-----IF ACA is struck down the above bet changes. Both camps will need to respond with a new proposals within the constraints laid out by the Court. The President might get a Mulligan - to lock in a new deal with only the popular provisions included, acceptable to maybe a third of House Republicans, passed and signed. Or he can carry the issue into the election.

By TOM PERKINS A recent announcement by the U.S. Preventative Health Service can rather simply be summed up: Most men eventually get prostate cancer, but most don't die from it; those who do are mostly over 75 years of age, so that ends their continuing burden on the public purse. Further, early and prolonged testing is expensive, and can lead to medical complications from biopsy examination.

Happily I can report that I have successfully completed my 80th trip around the sun. A few years ago prostrate cancer was detected by my annual prostate-specific antigen (PSA) test; it was of a particularly aggressive type, as revealed by a routine biopsy.

That test led to surgery, radiation and hormone therapy.

Unfortunately, the cancer returned, and for the last couple of years I have been undergoing both routine and quite advanced experimental therapies, and everything has been monitored and controlled by PSA tests. Happily, the cancer has been knocked off its feet, and though not eliminated, it is controlled to the point that I am writing this from Fiji where I am actively scuba diving every day. (Fiji is a marvelous place for that sport, my favorite.)

Life is full of ironies. The PSA test was developed by a Kleiner & Perkins company, Hybritech, in the mid 1970s. How happy I am that Eugene Kleiner and I backed that effort so long ago; the partnership no longer has the remotest financial interest in the field, so these thoughts are not motivated by any residual economic involvement.

It's hard to avoid a political aside, so I won't try. A healthy market-driven free economy leads to innovation and the development of breakthroughs, like the PSA test. A highly taxed and highly regulated economy leads to "Death Panels," like the U.S. Preventative Health Service.

Mr. Perkins is the founding partner of Kleiner Perkins Caufield and Byers, a prominent Silicon Valley venture capital partnership. He is also a retired director of The News Corporation.

The Supreme Court hasn’t yet rendered its verdict on Obamacare, but the nation’s doctors have. And they think it will wreck America’s health care system.

The latest evidence comes from a new survey of young doctors by the Physicians Foundation. Nearly 60 percent of doctors aged 40 and under are pessimistic about the future of American health care. Just 22 percent are optimistic.

The number-one reason doctors cited for their pessimism? Obamacare, which was singled out by more than a third. Add in related concerns — like distrust of government to do the right thing and the feeling that government intervention hurts patient care — and the docs’ hostility to Obamacare becomes even more intense.

When asked specifically for their diagnosis of Obama- care, just 23 percent say it will have a positive impact on their practice. Half say the effect will be negative.

These findings line up with an earlier survey of doctors by consulting firm Deloitte, which found that two-thirds of all doctors expect the quality of health care to decline under Obama- care.

Physician pessimism is understandable, as Obama- care’s promises are crumbling even before the law takes full effect.

For example, Americans were promised repeatedly that they could keep their insurance if they liked it. But the Congressional Budget Office (CBO) now admits that as many as 20 million people could lose their employer-provided coverage and have to buy insurance on government-run exchanges.

Obamacare was also supposed to bend the health care cost curve down, but the government now estimates that it will add more than $300 billion to the nation’s health tab over the next decade. According to the CBO, the cost of the law over the decade commencing in 2010 has risen to $1.76 trillion — almost double the original estimate of $940 billion.

Why should doctors trust that Obama- care’s other promises about improving the quality of care will be any more reliable? After all, Obamacare contains several provisions expressly designed to limit doctors’ ability to effectively treat their patients.

Take the law’s Accountable Care Organizations (ACOs). These integrated networks of health care providers are supposed to improve the coordination of Medicare patients’ care by bringing multiple doctors under one roof.

Improved communication among doctors should lead to less waste and lower costs — or so the theory goes.

But according to the Cleveland Clinic — one of the health systems that inspired the ACOs — the administration’s rules are “replete with prescriptive requirements that have little to do with outcomes” and “detailed governance and reporting requirements that create significant administrative burdens.”

In other words, ACOs will effectively dictate to doctors how they must treat their patients.

But the panel cannot make any changes to Medicare’s fee-for-service structure or adjust the level of benefits that seniors receive. So the board has only one legitimate option for getting Medicare spending under the targets — lowering reimbursement rates for doctors, nurses and hospitals.

Lower reimbursements may cause some providers to reduce the number of Medicare patients they’ll see — or refuse to treat them altogether.

Already, some doctors are shutting their doors to senior citizens. An American Medical Association survey found that nearly a third of primary care physicians restrict the number of Medicare patients they will see.

Another Obamacare creation, the Patient-Centered Outcomes Research Institute, will be just as destructive as IPAB. It is supposed to improve health care quality by comparing the effectiveness of different treatments.

But this “outcomes research” will likely be used to create top-down treatment guidelines that physicians will be expected to follow in order to get paid — even if the recommendations contradict their judgment of what’s best for a particular patient.

Such research led federal officials to recommend three years ago that women avoid getting regular mammograms in their 40s, even though breast cancer is the leading cause of death in women aged 35 to 50.

The Supreme Court could invalidate Obamacare in its entirety this June, when it renders its verdict on the law’s constitutionality. If it doesn’t, then Congress will need to heed the warning coming from the nation’s doctors that Obamacare is the wrong prescription for the nation’s health care system.

Sally C. Pipes is president and CEO of the Pacific Research Institute.

Regarding Crafty's post about the PSA test a few things I would chime in.

Mr. Perkins situation with the prostate cancer is a shame to say the least.

The problem is that the PSA test is not a good screening test.

It is not that it costs too much. It is that studies have not been able to show a net benefit. Not in terms of cost but in terms of human harm vs. good. At best statistically 1,400 men would have to be screened for maybe, one would not die as soon as expected from prostate cancer. Around 50 other will have surgery or radiation without any statistical benefit yet they may be harmed with anxiety, pain, impotence, urinary incontinence and the rest.

While prostate cancer is serious, and many men do die, the vast majority will never know they have it or ever have any problem from it.

Most experts from what I read do not recommend doctors recommend the test unless the patient wants it or has some other high risk to get one.

From what I am rading in the journals is that the only ones who are still recommending it are some of the urologists.

I still do a digital exam and offer the PSA test with more or less the above statistics and allow the patinet the choice.

For better disclosure in that the use of PSA screening is still advocated by many though again it seems like mostly urologists. On one hand the urologist deal with prostate disease more than anyone else and are most qualified. At the same time they also have a financial stake in this. Here is one of the two Fox news health commentators advocating for the test as a screening test. It is noteworthy that he IS a urologist. However, I noted that today, in direct contradiction to himself a few weeks ago Dr. Siegal who is an internist also recommneded the test. I have disagreed with him before and with a few things he said today. In this case I agree with the USPTF that the test appears to do more harm than good and is of unclear or rare benefit benefit. That said, the best course may be to use it with symptoms, with a family history, or if digital rectal exam is abnormal and with full disclosure to the patient about all of the above based upon their decision.

Apparantly the next big *screening* "debate" is going to be for yearly chest cat scans on patients who are high risk for lung cancer - smokers or previous smokers. You will all start hearing more and more about this too.

The infinite iterations of humans and the universe we live in is mind boggling. And exhausting at least to me - not exciting just tiring.

CDC has good summary of pros and cons of PSA screening. There is a link for a file for African American men that can be found at the CDC website too. They, for unknown reasons, have a higher risk. I think I will start referring people here to read up on testing and let them decide if they want it. While I certainly do not want to be giving advice here on the board, because I have posted previously on the subject, I feel it necessary to clarify with the best available information on the subject which is still a controversial subject. I read at least 3 or 4 reviews that conclude routine screening is probably more harm than good and one author states something to the effect the era of PSA screening for all men is over. Then within a few weeks is the backlash not unlike the breast cancer screening controversy not too long ago. I hope this clarifies to some extnet the present knowledge and I didn't confuse anyone:

At least one candidate is prepared for however the Supreme Court rules next week on the health care overhaul law — although Indiana’s GOP Senate nominee, Richard Mourdock, probably didn’t want the world to know it.

Mourdock’s campaign uploaded four videos to respond to the high court’s imminent decision — and each one has a different answer depending on the ruling.

I don't agree with every suggestion here (I disagree with the English rule or shortening the educational requirements) but overall a good effort I think:====================

http://pjmedia.com/blog/if-obamacare-dies-whats-next-for-health-care/?singlepage=trueIf Obamacare Dies, What’s Next for Health Care?Eight health care fixes for the Romney campaign to consider.byDr. Peter WeissBioJune 26, 2012 - 12:00 amThe Supreme Court declaring Obamacare dead will not necessarily help Governor Romney and the Republicans — the death of one monarch may lead to another monarch. We need the proper bill to replace it.When I was a health care advisor for the John McCain campaign — and an ardent, vocal opponent of Obamacare — I wrote of many possible solutions to alleviate our health care dilemma. It is time to reiterate them, with some adjustments. My basic mantra for health care reform: Keep it simple, stupid. Listen up, Governor Romney:1. Abolish all state mandates. State mandates contribute to billions in additional costs to the basic insurance premiums. Let the market dictate what is covered.2. Allow health insurance coverage to cross state lines.3. Allow affinity groups to offer insurance to their members. This would allow churches, synagogues, AAA, AARP, and even Costco to offer health care insurance to their members. The sheer numbers from membership will bring competition from the different carriers to provide the most coverage for the least cost. Some of these groups may even offer lifetime memberships, which in turn would afford the member similar health coverage regardless of job insurance.4. Allow catastrophic or major illness insurance. By removing forced state mandates, you will allow very reasonable catastrophic insurance policies. A 20-year-old healthy person should not be forced to pay for colon cancer screening.5. Allow physicians to be just that. If a physician — notice I did not call him or her a health care provider — is a “provider” for a particular health insurance plan, then whatever he or she orders must be accepted by that plan. The insurance company can economically credential these physicians every two years. They can even remove them if they feel they are too “generous.” The patient should not be used as a pawn.The above five constitute the “easy” solutions. Now come the hard ones.6. We must remove the Vegas-style gambling on medical law suits. You’ve seen the commercials: “Have you ever had a headache? You may be entitled to compensation.” I’ve proposed several solutions over the past few years, but have come to the conclusion that the simplicity of the English system — the “loser pays” system — would be best for America. No one is prevented from suing, but there would be no free roll of the dice. There must be money on the table to force accountability. There is always risk in life: if you sue and lose, you pay the cost.7. Allow re-importation of drugs. It is simple and it is safe. Did I mention simple?8. This one is a stretch, but I love it. Make medical school free, and shorten the four years of college, four years of medical school to six total years. Make all state schools free or nearly so. In return, the young doctor will give back to his state two to three years of service: two years if served after basic training (general practice), or three years after specialty training. This will encourage generalists. Private schools will still run the same, but will be at the cost of the student.When confronted with a complex medical condition, we as physicians are trained to find as simple a solution as possible by breaking down the components and solving the critical problems first, and then worrying about the minor ailments. While these eight steps may not “cure” what ails all of health care, they will allow the freedom of choice that Americans are entitled to. There is no one-size-fits-all answer.

A safer version of the desfenfluramine drug approved today - arena pharm - should be marginally helpfulSo will vivus pharm combination of topomax/phentermine recommended for approval.

The latter one pisses me off. Around two weeks before it was rec. for approval I read it had up to a 13% weight loss success which is more than any other. I thought I should buy in but was too afraid - every single pharm company I ever bought into was a loss for me. Of course, this time, two weeks later, the price went from 10 or 11 to 22 overnight.

Back at the at the dawn of ObamaCare in June 2009, speaking to the American Medical Association's annual meeting, President Obama said: "No matter how we reform health care, we will keep this promise: If you like your doctor, you will be able to keep your doctor. Period."

But will your doctor be able to keep you? Or will your doctor even want to keep you, rather than quit medicine?

For the longest time now, since day one of the Affordable Care Act, we have been having arguments over the mandate to purchase health-care insurance, requirements that insurance companies accept policyholders regardless of health, and price discrimination in insurance policies.

Corbis .And of course this past week, the Supreme Court—or something resembling the Supreme Court—outputted a decision on the tax status of the insurance-purchase mandate, the states' obligation to pay for Medicaid and as a bonus, the Commerce Clause.

Have you noticed what got lost in this historic rumble? Doctors. Remember them?

ObamaCare has been a war over the processing of insurance claims. It has been fought by institutional interests representing insurance, hospital and pharmaceutical firms. The doctor-patient relationship, or what used to be called "the practice of medicine," has sunk beneath these waves.

Barack Obama, a savvy pol, understood from the start that rationalizing payments claims through the maw of these private and public bureaucracies was not what the average person thinks of as "health care." To any normal person, health care means that when you or yours get really sick, the doctors and nurses who attend to you will push all else aside to give you medical help.

Thus, the constant Obama chorus that you can "keep your own doctor." No one knows better than Barack Obama that his law sends the nation's doctors on a voyage into an uncharted health-care world in which they are just along for the ride with their patients.

A Wall Street Journal story the day after the Supreme Court ruling examined in detail its impact across the "health sector." The words "doctor," "physician" and "nurse" appeared nowhere in this report. The piece, however, did cite the view of one CEO who runs a chain of hospitals, explaining how they'd deal with the law's expected $155 billion in compensation cuts. "We will make it up in volume," he said.

Volume? Would that be another word for human beings? It is now. At Obama Memorial, docs won't be treating patients. They'll be processing "volume." And then, with what time and energy remains in the day, they'll be inputting medical data to comply with the law's new Physician Quality Reporting System (PQRS), lodged in the Centers for Medicare and Medicaid.

Here's the Centers' own description of what PQRS does: "The program provides an incentive payment to practices with eligible professionals (identified on claims by their individual National Provider Identifier [NPI] and Tax Identification Number [TIN]) who satisfactorily report data on quality measures for covered Physician Fee Schedule (PFS) services furnished to Medicare Part B Fee-for-Service (FFS)."

We're all pressed for thinking time these days, but the one group we should make sure has time to focus on what's in front of them is doctors treating patients. Instead, they'll also be doing mandated data dumps for far-off panels of experts.

Doubts, even among believers, have begun to emerge about what ObamaCare could do to the practice of medicine. A remarkable and important piece by Drs. Christine K. Cassel and Sachin H. Jain in the June 17 Journal of the American Medical Association directly asks: "Does Measurement Suppress Motivation?"

The question raised by the article is whether imposing pay-for-performance measurements on individual physicians does more harm than good: "[C]lose attention must be given to whether and how these initiatives motivate physicians and not turn physicians into pawns working only toward specific measurable outcomes, losing the complex problem-solving and diagnostic capabilities essential to their role in quality of patient care, and diminish their sense of professional responsibility by making it a market commodity."

This is an important piece, because Dr. Cassel is part of the intellectual foundation for the measured-directives movement. The saying that comes to mind reading these misgivings is that it's better late than never to notice that the core relationship between doctor and patient is being eroded. Except that in the wake of Chief Justice Roberts's upholding of the Affordable Care Act, it's too late and we're beyond never.

Mitt Romney needs a way to talk about health care in America. This isn't just a fight over insurance companies. It's about the people at the center of health care—doctors. The Affordable Care Act will damage that most crucial of all life relationships, that between an ill person and his physician. Barack Obama's assertion that we all can keep our doctors is false. You could line up practicing physicians from here to Boston to explain to Mr. Romney why that is so.

In an editorial for The Week published Tuesday, the former majority leader of the Senate writes that both parties should support the insurance exchanges, noting that they were originally a “Republican idea.” A doctor, Frist says that he “sees little advantage” for Republican governors to refuse to set up exchanges in their own states and “default to the federally designed, one-size-fits-all exchange when they can design and run their own.”

Doctor Shortage Likely to Worsen With Health LawBy ANNIE LOWREY and ROBERT PEARPublished: July 28, 2012

RIVERSIDE, Calif. — In the Inland Empire, an economically depressed region in Southern California, President Obama’s health care law is expected to extend insurance coverage to more than 300,000 people by 2014. But coverage will not necessarily translate into care: Local health experts doubt there will be enough doctors to meet the area’s needs. There are not enough now.

Other places around the country, including the Mississippi Delta, Detroit and suburban Phoenix, face similar problems. The Association of American Medical Colleges estimates that in 2015 the country will have 62,900 fewer doctors than needed. And that number will more than double by 2025, as the expansion of insurance coverage and the aging of baby boomers drive up demand for care. Even without the health care law, the shortfall of doctors in 2025 would still exceed 100,000.

Health experts, including many who support the law, say there is little that the government or the medical profession will be able to do to close the gap by 2014, when the law begins extending coverage to about 30 million Americans. It typically takes a decade to train a doctor.

“We have a shortage of every kind of doctor, except for plastic surgeons and dermatologists,” said Dr. G. Richard Olds, the dean of the new medical school at the University of California, Riverside, founded in part to address the region’s doctor shortage. “We’ll have a 5,000-physician shortage in 10 years, no matter what anybody does.”

Experts describe a doctor shortage as an “invisible problem.” Patients still get care, but the process is often slow and difficult. In Riverside, it has left residents driving long distances to doctors, languishing on waiting lists, overusing emergency rooms and even forgoing care.

“It results in delayed care and higher levels of acuity,” said Dustin Corcoran, the chief executive of the California Medical Association, which represents 35,000 physicians. People “access the health care system through the emergency department, rather than establishing a relationship with a primary care physician who might keep them from getting sicker.”

In the Inland Empire, encompassing the counties of Riverside and San Bernardino, the shortage of doctors is already severe. The population of Riverside County swelled 42 percent in the 2000s, gaining more than 644,000 people. It has continued to grow despite the collapse of one of the country’s biggest property bubbles and a jobless rate of 11.8 percent in the Riverside-San Bernardino-Ontario metro area.

But the growth in the number of physicians has lagged, in no small part because the area has trouble attracting doctors, who might make more money and prefer living in nearby Orange County or Los Angeles.

A government council has recommended that a given region have 60 to 80 primary care doctors per 100,000 residents, and 85 to 105 specialists. The Inland Empire has about 40 primary care doctors and 70 specialists per 100,000 residents — the worst shortage in California, in both cases.

Moreover, across the country, fewer than half of primary care clinicians were accepting new Medicaid patients as of 2008, making it hard for the poor to find care even when they are eligible for Medicaid. The expansion of Medicaid accounts for more than one-third of the overall growth in coverage in President Obama’s health care law.

Providers say they are bracing for the surge of the newly insured into an already strained system.

Temetry Lindsey, the chief executive of Inland Behavioral & Health Services, which provides medical care to about 12,000 area residents, many of them low income, said she was speeding patient-processing systems, packing doctors’ schedules tighter and seeking to hire more physicians.

“We know we are going to be overrun at some point,” Ms. Lindsey said, estimating that the clinics would see new demand from 10,000 to 25,000 residents by 2014. She added that hiring new doctors had proved a struggle, in part because of the “stigma” of working in this part of California.

Across the country, a factor increasing demand, along with expansion of coverage in the law and simple population growth, is the aging of the baby boom generation. Medicare officials predict that enrollment will surge to 73.2 million in 2025, up 44 percent from 50.7 million this year.

“Older Americans require significantly more health care,” said Dr. Darrell G. Kirch, the president of the Association of American Medical Colleges. “Older individuals are more likely to have multiple chronic conditions, requiring more intensive, coordinated care.”

The pool of doctors has not kept pace, and will not, health experts said. Medical school enrollment is increasing, but not as fast as the population. The number of training positions for medical school graduates is lagging. Younger doctors are on average working fewer hours than their predecessors. And about a third of the country’s doctors are 55 or older, and nearing retirement.

Physician compensation is also an issue. The proportion of medical students choosing to enter primary care has declined in the past 15 years, as average earnings for primary care doctors and specialists, like orthopedic surgeons and radiologists, have diverged. A study by the Medical Group Management Association found that in 2010, primary care doctors made about $200,000 a year. Specialists often made twice as much.

The Obama administration has sought to ease the shortage. The health care law increases Medicaid’s primary care payment rates in 2013 and 2014. It also includes money to train new primary care doctors, reward them for working in underserved communities and strengthen community health centers.

But the provisions within the law are expected to increase the number of primary care doctors by perhaps 3,000 in the coming decade. Communities around the country need about 45,000.

Many health experts in California said that while they welcomed the expansion of coverage, they expected that the state simply would not be ready for the new demand. “It’s going to be necessary to use the resources that we have smarter” in light of the doctor shortages, said Dr. Mark D. Smith, who heads the California HealthCare Foundation, a nonprofit group.

Dr. Smith said building more walk-in clinics, allowing nurses to provide more care and encouraging doctors to work in teams would all be part of the answer. Mr. Corcoran of the California Medical Association also said the state would need to stop cutting Medicaid payment rates; instead, it needed to increase them to make seeing those patients economically feasible for doctors.

More doctors might be part of the answer as well. The U.C. Riverside medical school is hoping to enroll its first students in August 2013, and is planning a number of policies to encourage its graduates to stay in the area and practice primary care.

But Dr. Olds said changing how doctors provided care would be more important than minting new doctors. “I’m only adding 22 new students to this equation,” he said. “That’s not enough to put a dent in a 5,000-doctor shortage.”

Annie Lowrey reported from Riverside, and Robert Pear from Washington.

Scalia was on Chris Wallace's show this morning and said he had no thought of retirement. Also he did Pierce Morgan's show about a week ago. PM revealed himself to be a progressive ass in way over his head without even realizing it.

[T]he notion that Medicare has "less bureaucracy" than private insurers is deeply confused. . . . That sort of argument is often based on the claim that Medicare's ratio of administrative costs (the money it spends on things other than care) to health costs is lower than those of private insurance companies. But this misses some key facts.

To begin with, many of Medicare's most significant administrative costs are just covered by other federal agencies, and so don't appear on Medicare's particular budget, but are still huge costs of the program. The IRS collects the taxes that fund the program; Social Security collects many of the premiums paid by beneficiaries; HHS pays for a great deal of what you would think of as basic overhead, but doesn't put it on the Medicare program's budget. Obviously private insurers have to pay for such things themselves. Medicare's administration is also exempt from taxes, while insurers pay an excise tax on premiums (which is counted as overhead). And private insurers also spend a great deal of money fighting fraud, while Medicare doesn't. That might reduce the program's administrative costs, but it greatly increases its overall costs. Some administrative costs save money, after all: The GAO has estimated that a $1 investment in pre-payment review of claims, for instance, would save $21 in improper Medicare payments.

Moreover, because Medicare covers older (and therefore sicker) patients than most private insurers (who are locked out of that market), the ratio of its spending on coverage to its spending on overhead is very different from the one most private insurers have—if administrative costs for managing two patients are both $100 but one patient has $200 of health expenses in a year and the other has $2,000 of health expenses, the insurer that covers the first patient will have a far higher administrative-cost ratio, even though both have the same administrative costs. On a per-patient basis, Medicare's administrative costs most years are actually higher than those of private insurers, even though the program has all the enormous advantages just described in averting such costs and keeping them off the books.

One of the tragedies of the Obama Administration is the historic political accident that it had 60 Senate Democratic votes in 2009. The ability to break a filibuster without Republican votes empowered the left to think it could pass anything, and so it steamrolled ahead with ObamaCare, which needed every one of those 60 votes to pass.

Now a couple of those Senators are expressing regrets about those votes after the fact. In our pages last week, former Indiana Democrat Evan Bayh rehearsed the looming economic damage from ObamaCare's medical-device tax. He described, as some of us predicted in 2009 during the debate, how the tax is sending jobs and investment overseas in an industry where the U.S. still leads the world. Mr. Bayh, who retired after 2010, provided the 60th vote for ObamaCare to pass.

Another 60th vote, Virginia Senator Jim Webb, is also expressing second thoughts as he heads for retirement this year after one term. "My great regret on that is that I believe the whole health-care issue could have been handled differently by the Administration and over here," he told MSNBC recently. "I think the way that the process was put forward without a clear set of principles from the Administration caused a lot of fear in the country. We had seven different or five different committees boiling up 7,000 pages of contradictory information."

All true, but reporter Chuck Todd pressed if the Senator regretted his vote?

"No, and in the end I voted with the Republicans 18 times, but in the end I voted for it," Mr. Webb added. "We do need to move forward. We need to find different ways to work with these issues. We could have had a smaller, more focused package, and the country would have been a lot more comfortable with the process as well."

Even hedged regrets are welcome, but the irony is that a Senator who says the parties need to work more together will have as his main legacy the most partisan and polarizing legislation of modern times. Had he or any one of the 60 Democrats insisted that the Administration get Republican votes, or drop the bill's worst provisions, history would have been very different.

A second irony is that Democrats only had those 60 Senate votes because of a series of improbable and corrupt events. Mr. Webb won his race by a hair in 2006 after incumbent George Allen stupidly uttered the word "macaca," and the media portrayed him as racist. Alaska's Ted Stevens lost his seat in 2008 by 3,724 votes after he was convicted eight days before the election in a trial in which the Justice Department withheld crucial evidence. He was later exonerated. And Al Franken, who was trailing on Election Day, managed to steal the Minnesota recount in 2008 by 312 votes from a hapless Norm Coleman.

Add the Louisiana Purchase, the Cornhusker Kickback and the other special deals that President Obama used to buy Senate Democratic votes for ObamaCare, and you have the first major new entitlement in history that passed along strictly partisan lines and is as unpopular today as it was on the day it passed.

Messrs. Webb and Bayh can lament what might have been, but the bitter truth is that the only way voters can undo their damage is by defeating Mr. Obama in November and electing a Republican Senate. Otherwise, both men will have left their country economically weaker and health care less affordable than it was when they decided to run for office. That should be their real regret.

Secretary of Health and Human Services Kathleen Sebelius has been campaigning so enthusiastically for President Obama that she — whoops! — broke a federal law that restricts political activities by executive-branch officials. Federal employees are usually fired for such transgressions, but no one expects that to happen to Sebelius. Heck, she got right back in the saddle.

Every cabinet official (probably) wants to see the president reelected, and no president relishes dismissing a cabinet official. But in this case, there’s an additional incentive for Sebelius to campaign for her boss and for Obama not to fire her.

ObamaCare creates a new Independent Payment Advisory Board that — “fact checkers” notwithstanding — is actually a super-legislature with the power to ration care to everyone, increase taxes, impose conditions on federal grants to states, and wield other legislative powers. According to legend, IPAB will consist of 15 unelected “experts” who are appointed by the president and confirmed by the Senate. Yeah, good one.

In fact, if the president makes no appointments, or the Senate rejects the president’s appointees, then all of IPAB’s considerable powers fall to one person: the Secretary of Health and Human Services. The HHS secretary would effectively become an economic dictator, with more power over the health care sector than any chamber of Congress.

If Obama wins in November, he would have zero incentive to appoint any IPAB members. The confirmation hearings would be a bloodbath, not unlike Don Berwick’s confirmation battle multiplied by 15. Sebelius, on the other hand, would not need to be re-confirmed. She could assume all of IPAB’s powers without the Senate examining her fitness to wield those powers. If Obama fired her, or the voters fire Obama, then the next HHS secretary would have to secure Senate confirmation. Again, bloodbath. That makes Kathleen Sebelius the only person in the universe who could assume those powers without that scrutiny.

No wonder she’s campaigning so hard. No wonder Obama won’t fire her.

Why Sebelius Campaigns So Hard for Her Boss — and Why He Won’t Fire Her is a post from Cato @ Liberty - Cato Institute Blog

The Better Solution for 'Pre-Existing Conditions' There's no need to turn the entire system upside down to help the people who can't buy private insurance..By JOHN C. GOODMAN

Do you remember the debates over the Affordable Care Act, aka ObamaCare? Now that repeal of the law has become a major campaign issue, it may be helpful to remember why Congress passed it in the first place.

Early in 2010, as the climactic votes neared, a parade of the legislation's defenders—from the House, Senate and Obama administration—appeared across the media. All had the same message: pre-existing conditions. They named the names of families "victimized" by companies that had refused to sell them insurance, had canceled their coverage or had refused to pay their medical bills.

The message surely resonated, but how many people have actually been affected since the law passed? The Affordable Care Act established a federally funded risk pool—the Pre-Existing Condition Insurance Plan—that allows individuals with such disqualifying conditions to buy a policy for the same premium a healthy person would pay. About 82,000 people have signed up as of July 31, according to the Kaiser Family Foundation's statehealthfacts.org.

That is not a misprint. Out of a population of more than 300 million, some 82,000 have the problem that was cited as the principal reason for spending $1.8 trillion over the next 10 years and in the process turning the entire health-care system upside down.

The risk pool surely comes as welcome relief to those who need it. A lot of them are really sick and are running up expensive medical bills. But the three-year cost is about $5 billion, as budgeted in the Affordable Care Act—a tiny fraction of the law's overall burden. Nevertheless, the federal risk pool will be closed down in 2014, when ObamaCare will begin prohibiting insurance companies from charging premiums based on the health conditions of applicants.

Mitt Romney has vowed to repeal ObamaCare if he is elected president, but his plan for addressing pre-existing conditions is similar to it in some respects. Mr. Romney says he would require insurers to ignore pre-existing conditions for anyone who has been insured continuously for a certain period of time, such as through an employer's plan.

But when insurers are forced to charge the same premium to all applicants, regardless of expected health-care costs, prices will be wrong for everyone—and both buyers and sellers of health-care policies will have perverse incentives.

.On the buyer's side, healthy people who are overcharged will underinsure, buying less coverage than they otherwise would. They may even decide to go without insurance, since the ObamaCare penalties for being uninsured are weak and people can always buy a policy after they get sick. People with expensive health problems will overinsure, buying more generous coverage than they otherwise would.

Insurers, on the other hand, will try to sell policies to the healthy, on whom they expect to make a profit, while avoiding the unhealthy, on whom they expect to incur a loss,—and they will change the design of their plans to accomplish this goal.

Preventive care and wellness checkups with no deductible or copayment, for example, will attract and keep the healthy; insurers may even provide memberships in health clubs. But failure to include the best cancer-care center or the top heart clinic in a plan's network will discourage the sick from enrolling. Insurers may also underprovide for unhealthy people by failing to include the latest cancer drugs in their offerings.

These same incentives are present in the current system, but most people have insurance brokers or employers acting as their protectors. In a few years, however, the brokers will likely leave the market altogether and many employers will drop their coverage. Along the way, the federal government will put enormous pressure on insurers to keep their costs down. Then you will be on your own, facing a system that has no interest in spending money on you.

On health insurance generally, Mitt Romney surely has the better approach. He would give the same tax relief to individually purchased insurance as to employer-provided coverage. That would put portable insurance (owned by the individual) on equal footing with group insurance that must be forfeited when people change jobs. Portability would alleviate the problem for individuals who change or lose their jobs but have medical conditions. Also, repealing ObamaCare would mean that people wouldn't be able to game the system by waiting to buy insurance until after they get sick.

For those who have not been continuously insured, Mr. Romney favors risk pools. This is a cheaper and less destructive solution to the problem of pre-existing conditions. But here the danger is that risk pools must be structured judiciously, lest they also encourage the healthy to remain uninsured.

There is an even better idea: to insure yourself against the possibility of becoming uninsurable, as suggested by economists including the University of Chicago's John Cochrane on this page in April. Under this approach, policies would be guaranteed to be renewable and include the right to buy another policy in the future. If your health condition worsens, a new insurer would be free to charge you a higher premium. But the old insurer would pay the extra premium caused by the change in your health status.

Mr. Goodman is president of the National Center for Policy Analysis and author of "Priceless: Curing the Healthcare Crisis" (Independent Institute, 2012).

'Concierge' Medicine, ObamaCare and the End of Empathy Traditional primary-care doctors are finding themselves, and their patients, squeezed by the government and the marketplace..Article Comments (24) more in Opinion | Find New $LINKTEXTFIND$ ».smaller Larger facebooktwittergoogle pluslinked ininShare.0EmailPrintSave ↓ More ..smaller Larger By JERALD WINAKUR I call my cousin Irene regularly. She is 90, frail, living alone in New York in an apartment in Queens, and I worry about her. This time there is distress in her voice:

"I just don't know what I'm going to do. I got a letter from my doctor, the one I've been seeing for a long time. It said she was making some changes to her practice. I had to go to a reception at a hotel in Manhattan where the details would be explained. I have such a hard time getting into the city, so I called her office to see if someone couldn't just tell me over the phone."

Irene was crying now. "No, they said, I needed to come to the reception. So I paid a car service to take me there and back."

What Irene learned was that her internist was converting her fee-for-service office into a "concierge practice." For a yearly retainer of $2,200 (in addition to the usual charges that would still be billed through Medicare and supplemental insurance), Irene would receive "value-added" services. These include same-day appointments, electronic access to her medical records and lab reports, shortened waiting times, and other "frills" that Irene said her doctor always provided anyway.

"Do you think I should do it?" Irene asked me, her younger cousin, the doctor in the family, the internist and geriatrician. "I don't even own a computer."

My cousin, of course, is not alone. This same question is being asked by patients, many of them elderly, all over the country as more primary-care doctors opt for the concierge model.

Meanwhile, companies are springing up to help doctors make the change. For a piece of the action, they help transform a struggling primary-care practice into a well-oiled profit center.

As one such company, SignatureMD, advertises on its website: "It can be challenging for any physician to remain independent and profitable in the face of severe reimbursement cuts, increased regulation, and increased overhead. Our seasoned team of professionals have devoted years to developing a high reward, low risk concierge practice model. SignatureMD enables you to deliver the care that your patients desire while securing your financial independence."

Don't get me wrong, for nearly 40 years I practiced as a primary-care internist and geriatrician, so I understand both sides of this issue. Primary-care doctors have been undervalued and under-reimbursed by Medicare since the inception of the program. There has not been a real increase in fees in the past decade, during which time costs have soared.

"If you like this doctor, and you want to keep seeing her," I said to Irene, "you won't have a choice—you'll have to join her concierge practice."

The Affordable Care Act, in theory, places more value on primary-care services. But so far this remains just theory. At the medical school where I teach, only a small minority of students are considering primary care as a career choice. That's not unusual. Worse, in an era of burgeoning need, just 2% of young doctors in residency express any interest in geriatric medicine.

Those of us who have spent our careers in the cottage industry of medical practice and working in America's single-payer health-care system known as Medicare hear only this nowadays: "Get ready, changes are coming." The talk is all wonky babble about "primary care medical homes," "accountable care organizations," "service bundling" and "resource-based relative value units." Through the din, one thing is clear: The single practitioner will be unable to survive without joining some much larger entity, or by transforming into a concierge model.

Medicare now looks the other way as the concierge-medicine movement grows. In times past, had physicians attempted to charge Medicare patients additional fees while still billing this agency for services rendered, all manner of fines and sanctions would have been imposed. No more. With the nation short 40,000 primary-care doctors—and that's before 30 million more patients come on board in 2014 due to the Affordable Care Act—the policy gurus have looked around and concluded that they can't afford to alienate the worker bees that still remain.

Yet as financially tempting as a concierge practice might be, I could never have turned away a patient unable to come up with an annual retainer fee. I had a history with each and every one of them. They were my "family." I tried to treat each of my patients equally and with the full measure of my time and concern. To do otherwise violates the basic justice principle of medical ethics that we teach medical students today.

The last time I spoke to Irene, I asked her if she had been back to her internist since she had decided to pay the annual retainer. "I was in to see her last week," she said. "Everything works the same way it did before—even though I'm paying all this extra money. . . . I just don't feel the same about my doctor anymore."

I must ask: Are we witnessing the end of empathy in the practice of medicine?

Dr. Winkaur practiced internal and geriatric medicine for 36 years. He is a clinical professor of medicine at the University of Texas Health Science Center at San Antonio, and the author of "Memory Lessons: A Doctor's Story" (Hyperion, 2009).

It's been hashed out in the comments on this blog before -- contract attorneys in Washington are, by and large, liberals. Usually, very liberal. By this of course, we mean the old-school, early 1900s Progressives, not the classic, Thomas Jefferson liberals. We're talking about the far leftists who changed their label from Progressive to Liberal when Progressive became a pejorative, then back to Progressive when Liberal became a pejorative and people had forgotten that Progressive used to be a pejorative.

Philosophy aside, it is important to realize that elections have consequences. One of the consequences of this election is that Obamacare is here to stay, at least for a while. It is too inherently unworkable to stay for long, but it isn't going away in the next few years. Live with it.

Liberal contract attorneys might want to consider what "live with it" means. Under Obamacare, companies with 50 or more full-time employees either have to provide them with government-approved health insurance policies, or pay a per-employee fine. Further, the fine kicks in at the 31st employee, not the 51st, and it starts at $2,000 per year per employee. It goes up later. Companies, therefore, are discouraged from having full-time employees, or at least 50 or more of them. Hello, part-time employment. Think I'm fucking with you? Think again.

While you're thinking again, start thinking about the industry in which you work. Obamacare, unlike other government regulations, defines a full-time employee as one working 30 hours a week. Every temp agency in town worth a shit has 50 people working "full-time" in any given year under that definition. If you think that temp agencies will give you employer-funded health insurance that meets Obamacare standards (hint: lots of mandates make insurance less affordable), you are delusional. They already didn't offer comprehensive insurance, which was cheaper before Obamacare started affecting rates, so they won't start now. They also are not going to pay the penalty. Margins are too thin. What will the agencies do?

There are only two choices. First, nobody works 30 hours a week for an agency ever again. That probably is an unworkable solution, but it is not unthinkable, given the trend in the industry toward a 40-hour cap on projects. A 30-hour cap would mean more bodies, staggered, but would not be a dramatic departure from the no-OT policy that already governs so many projects. Given the staggering costs of forced health coverage (or penalties), agencies won't consider this option unworkable. They'll think about it, and you'll have to start finding two projects at a time to make a living wage. Assuming, of course, that agencies and the firms that hire them stop enforcing their concurrent employment policies that ban working two projects at a time.

The second choice is, your taxes just got harder. Agencies could deem contract attorneys to be independent contractors and start issuing 1099s instead of W-2s. That means you'll have to make quarterly estimated tax payments for withholding, Social Security and Medicare taxes. Oh, and by the way, it also means you'll be responsible for the employer's half of those Social Security and Medicare payroll taxes, as you will now be self employed. Of course agencies will raise your rates to make up for the fact that your share of the payroll taxes doubled while their share disappeared. Don't doubt it for a second. Yeah, you're fucked.

One way or another, you're fucked. Temporary employment as we know it is unlikely to survive Obamacare, at least as it is currently structured. That's not my opinion, that's what temp agency heads said to Congress. I suggest you read the entire transcript. These guys have a pretty good idea of how Obamacare will fuck their industry and, by extension, you.

But don't worry about them. Maybe they're full of shit. Maybe you'll be fine. Or maybe you're fucked. but hey, that's what you voted for.

From GM's post: "Under Obamacare, companies with 50 or more full-time employees either have to provide them with government-approved health insurance policies, or pay a per-employee fine. Further, the fine kicks in at the 31st employee, not the 51st, and it starts at $2,000 per year per employee. It goes up later. Companies, therefore, are discouraged from having full-time employees, or at least 50 or more of them."

What is a full time employee? The new federal definition of a full time employee is eighteen pages long. http://washingtonexaminer.com/feds-need-18-pages-to-define-full-time-for-obamacare/article/2507528

Capretta and Levin: Why ObamaCare Is Still No Sure Thing The majority of state governors are Republicans, and they have the power to disarm the health-care law..By JAMES C. CAPRETTA AND YUVAL LEVIN

Champions of ObamaCare want Americans to believe that the president's re-election ended the battle over the law. It did no such thing. The Patient Protection and Affordable Care Act won't be fully repealed while Barack Obama is in office, but the administration is heavily dependent on the states for its implementation.

Republicans will hold 30 governorships starting in January, and at last week's meeting of the Republican Governors Association they made it clear that they remain highly critical of the health law. Some Republican governors—including incoming RGA Chairman Bobby Jindal of Louisiana, Ohio's John Kasich, Wisconsin's Scott Walker and Maine's Paul LePage—have already said they won't do the federal government's bidding. Several Democratic governors, including Missouri's Jay Nixon and West Virginia's Earl Ray Tomblin, have also expressed serious concerns.

Talk of the law's inevitability is intended to pressure these governors into implementing it on the administration's behalf. But states still have two key choices to make that together will put them in the driver's seat: whether to create state health-insurance exchanges, and whether to expand Medicaid. They should say "no" to both.

At its core, ObamaCare is a massive entitlement expansion. Between vastly increased Medicaid eligibility and new premium subsidies, it is expected to bring 30 million more people onto the federal government's entitlement rolls. The law anticipates that the states will take on the burden of implementing the expansions, but states can opt out of both.

Running the exchanges would be an administrative nightmare for states, requiring a complicated set of rules, mandates, databases and interfaces to establish eligibility, funnel subsidies, and facilitate purchases. All of this would have to take place under broad and often incoherent statutory requirements and federal regulations that have yet to be written.

The exchanges would create unsustainable pressures on each state's insurance market, treating similarly situated people differently by providing far greater subsidies for those in the exchanges than those in employer plans—yielding perverse incentives that distort consumer and employer decisions and increase costs.

States would endure all this simply to become functionaries of the federal government. The idea that creating state exchanges would give states control over their insurance markets is a fantasy. The states would be enforcing a federal law and federal regulations, with very little room for independent judgment.

Governors know this. A group of them has already indicated that they will not build the exchanges, and several more seemed ready to opt out as the administration's deadline for state decisions approached on Nov. 16. Predictably, Health and Human Services Secretary Kathleen Sebelius tried to head them off by extending the deadline to Dec. 14. She will try to use the extra month to twist governors' arms. They should resist.

By declining to build exchanges, the states would pass the burden and costs of the exchanges to the administration that sought this law. And it is far from clear that the administration could operate the exchanges on its own.

Congress didn't allocate money for administering federal exchanges, and the law as written seems to prohibit federally run exchanges from providing subsidies to individuals. The administration insists that it can provide those subsidies anyway. But if the courts read the plain words of the statute, then federal exchanges couldn't really function.

Thus states that refuse to create their own exchanges would effectively be repealing a large part of the law—sparing their citizens from the job-killing employer mandate and from assaults on their religious liberty. In some cases people would even be spared from the individual mandate to buy coverage, since in the absence of exchange subsidies more families would qualify for exemptions from the mandate.

The Medicaid expansion, meanwhile, would throw millions of additional Americans into a system that is already bankrupting state governments and increasing costs in the private-insurance market. Medicaid's payments for services are so low that many existing beneficiaries have trouble finding physicians and other health-care providers who will accept them as patients. Enrolling more people without reform will push the system to the point of collapse.

In refusing the Medicaid expansion, governors should notify Washington that doing so means freeing themselves of ObamaCare's "Maintenance of Effort" requirements. These would prohibit states participating in the Medicaid expansion from reforming their Medicaid systems to reduce costs.

Instead of following the Obama administration's plan, states should seek real reform. For example, they should demand that Washington transform the federal portion of Medicaid for non-disabled and non-elderly beneficiaries into a uniform block grant, with state discretion over eligibility and benefits. The goal should be to turn Medicaid into a premium-assistance program rather than government-run insurance. Medicaid could then be used to help people enroll in mainstream insurance plans. This is the way to help the low-income uninsured get the same kind of coverage as other Americans.

President Obama won re-election and Democrats maintained control of the Senate this month, but the states hold the future of ObamaCare in their hands. Knowing the harm the law would do to their citizens, to the economy and to American health care, governors should refuse to become its enablers.

Mr. Capretta is a fellow at the Ethics and Public Policy Center and a visiting fellow at the American Enterprise Institute. Mr. Levin is a fellow at the EPPC and editor of National Affairs.